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Article
Publication date: 5 June 2017

William Trombetta

Providing health care to the poor is evolving in the new US marketplace. The Affordable Care Act has set goals enhancing access to health care, lowering costs and…

Abstract

Purpose

Providing health care to the poor is evolving in the new US marketplace. The Affordable Care Act has set goals enhancing access to health care, lowering costs and improving patient outcomes. A key segment in this evolution is the most vulnerable health-care population of all: Medicaid. This paper aims to provide a general review of how providing health care to Medicaid patients is changing including how socio-economic aspects of this vulnerable population affects the quality of the health care provided.

Design/methodology/approach

The paper is entirely secondary research; no primary research has been conducted.

Findings

Managed care Medicaid provides a risk-based model to treating a vulnerable health-care market segment. The jury is still out on whether managed care Medicaid (MCM) is improving health-care quality and saving cost, but the provision of health care to the Medicaid segment is definitely shifting from a fee-for-service model to value based payment. Very recent developments of new health-care delivery approaches present a positive outlook for improving quality and containing costs going forward.

Research limitations/implications

At this stage, whether or not MCM saves money or provides better health-care quality to this vulnerable population is a work in progress. Health-care marketing can impact socio-economic aspects of health care for the poor. There is a need to follow up on the positive results being documented in demonstration health-care delivery models.

Practical implications

At this point, there has been no long-term study of whether managed care Medicaid offers better quality of health care and cost savings. The research to date suggest that the quality of health-care delivery to the poor is improving at a lower cost to payers.

Social implications

Medicaid patients are an underserved market segment. Managed care Medicaid offers a new model that has the potential to provide quality care at acceptable cost. Critical to this vulnerable market segment is the need to integrate socio-economic aspects of the population with the delivery of health care.

Originality/value

There has been very little discussion of Medicaid overall in the marketing literature, much less any discussion of managed care Medicaid.

Details

International Journal of Pharmaceutical and Healthcare Marketing, vol. 11 no. 2
Type: Research Article
ISSN: 1750-6123

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Article
Publication date: 1 October 2004

Kristina L. Guo

This paper describes major trends in the health care market. They include increased health care costs, the growth of managed care, emphasis on quality of care, consumer…

Abstract

This paper describes major trends in the health care market. They include increased health care costs, the growth of managed care, emphasis on quality of care, consumer choice and the growth of the elderly and uninsured populations. The relationship between cost, quality, managed care and choice are explored in the Medicare and Medicaid programs. A clearer understanding of these trends enables managers in health care organizations to make strategic decisions resulting in organizations' survival and growth.

Details

Journal of Health Organization and Management, vol. 18 no. 5
Type: Research Article
ISSN: 1477-7266

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Article
Publication date: 1 September 2000

Wally R. Smith, J. James Cotter, Donna K. McClish, Viktor E. Bovbjerg and Louis F. Rossiter

We determined access and satisfaction of 2,598 recipients of Virginia’s Medicaid program, comparing its health maintenance organizations (HMOs) to its primary care case…

Abstract

We determined access and satisfaction of 2,598 recipients of Virginia’s Medicaid program, comparing its health maintenance organizations (HMOs) to its primary care case management (PCCM) program. Positive responses were summed as sub‐domains either of access, satisfaction, or of utilization, and adjusted odds ratios were calculated for HMO (vs. PCCM) sub‐domain scores. The response rate was 47 per cent. We found few significant differences in perceived access, satisfaction, and utilization. Both HMO adults and children more often perceived good geographic access (adults, OR, [CI] = 1.50, [1.04‐2.16]; children, OR, [CI] = 1.773 [1.158, 2.716]). But HMO patients less often reported good after‐hours access (adults, OR, [CI] = 0.527 [0.335, 0.830]; children, OR, [CI] = 0.583 [0.380, 0.894]). Among all patients reporting poorer function, HMO patients more often reported good general and preventive care (OR, [CI] = 2.735 [1.138, 6.575]). We found some differences between Medicaid HMO versus PCCM recipients’ reported access, satisfaction, and utilization, but were unable to validate concerns about access and quality under more restrictive forms of Medicaid managed care.

Details

British Journal of Clinical Governance, vol. 5 no. 3
Type: Research Article
ISSN: 1466-4100

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Book part
Publication date: 21 October 2008

Ashley A. Dunham, Teresa L. Scheid and William P. Brandon

This chapter explores how primary care physicians deliver mental health treatment for Medicaid patients in one county in the United States, and how treatment may have…

Abstract

This chapter explores how primary care physicians deliver mental health treatment for Medicaid patients in one county in the United States, and how treatment may have changed after HMO enrollment with a mental health carve-out. We utilize Lipsky's theory of street-level bureaucracy to better understand how primary care physicians treat Medicaid patients for depression and what types of insurance arrangements support or inhibit that treatment. Exploratory interviews with 20 physicians revealed that the patient's status as a non-voluntary client, service system barriers and physicians’ commitment to treatment caused them to bear primary responsibility for the majority of depression care. Physicians were willing to act as advocates for their clients and viewed such advocacy as ethical given the lack of mental health parity. In general, primary care physicians were not familiar with new policies dictating mental health carve-outs for Medicaid patients, nor were they concerned with how mental health care was reimbursed for their patients. However, they were willing to provide mental health care even if they were not reimbursed. Physicians rely upon medication management to treat depression, and reimbursement plays a role in the amount of time spent with patients and in the coding used for the visit. Lipsky's (1980) theory of street-level bureaucracy provides a useful framework for understanding how physicians will act as advocates for their clients in the face of structural as well as resource constraints on health care.

Details

Care for Major Health Problems and Population Health Concerns: Impacts on Patients, Providers and Policy
Type: Book
ISBN: 978-1-84855-160-2

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Article
Publication date: 1 October 2005

Daniel Simonet

In the USA, health maintenance organizations (HMOs) have pledged to control health care costs. Many patients have complained about the quality of care under the HMO regime…

Abstract

Purpose

In the USA, health maintenance organizations (HMOs) have pledged to control health care costs. Many patients have complained about the quality of care under the HMO regime and limits imposed on them, particularly access to care. Has quality of care been degraded under the HMO regime, resulting in an impact on patient satisfaction? There have been many studies that have compared the satisfaction of HMO patients with that of patients in the traditional fee‐for‐service payment system. The aim of this paper is to review HMO patient satisfaction.

Design/methodology/approach

A review of patient satisfaction under managed care arrangements with a focus on HMOs. The article describes the US history of managed care and its effect on the satisfaction of several patient categories including the general population, vulnerable patients and the elderly.

Findings

There is much information available on patient satisfaction with their insurers and most surveys indicate the lack of choice of a provider – a major source of discontent. Therefore, patient protection laws are necessary to avoid abuse.

Originality/value

Patients have little ability or are not willing to rely on the information available when selecting a provider. The paper discusses patient awareness regarding satisfaction surveys and how the latter can be used when patients are seeking care.

Details

International Journal of Health Care Quality Assurance, vol. 18 no. 6
Type: Research Article
ISSN: 0952-6862

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Book part
Publication date: 29 July 2009

Arpita Chattopadhyay

This study examines the variation in preventable hospitalization rates of Medicaid children in California to extend our understanding of racial and ethnic disparity in…

Abstract

This study examines the variation in preventable hospitalization rates of Medicaid children in California to extend our understanding of racial and ethnic disparity in primary care quality. The results show that primary care quality varies substantially by race and ethnicity even when financial access is ensured by Medicaid. Moreover, the domain of primary care that minority children experience disadvantage varies by race and ethnicity. Compared to white children, African-American children lack continuity and comprehensiveness of care that is necessary for the management of chronic conditions. Hispanic children, on the contrary, have inadequate first contact care. Asian children experience a better quality of care overall than white children. Independent of race, a primary language other than English has a protective effect on preventable hospitalization rates, indicating that language need not be a barrier to quality primary care for racial and ethnic minority groups. The possible reasons underlying the observed differences in health outcome by race/ethnicity and primary language are discussed.

Details

Social Sources of Disparities in Health and Health Care and Linkages to Policy, Population Concerns and Providers of Care
Type: Book
ISBN: 978-1-84855-835-9

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Book part
Publication date: 6 December 2005

Margaret and Sheldon R. Gelman

Managed care refers to a variety of integrated financing and delivery procedures for controlling, coordinating, and monitoring the delivery of health care to limit overuse…

Abstract

Managed care refers to a variety of integrated financing and delivery procedures for controlling, coordinating, and monitoring the delivery of health care to limit overuse of services and over-charging by professionals and to ensure that health care planning is consistent with MCO standards which may, or may not, coincide with professional standards (Barakat, 2000; Gibelman, 2001/2002). Following enactment, in 1965, of Medicare and Medicaid, utilization rates for health services exploded (Mitchell, 1998). Included in this escalating total was an increasing proportion of costs for mental health and social services. Older adults generally require more medical care and services than do younger people; with Medicare coverage, consumers had access to more of the services they needed with much of the cost covered by government. The poor have traditionally been under-utilizers of health and mental health care services, primarily because these services were unaffordable. With Medicaid, barriers to access were removed. Significantly, the population which benefitted from government health and mental health programs was to later feel the brunt of cost management efforts (Gibelman, 2001/2002).

Details

Crisis and Opportunity in the Professions
Type: Book
ISBN: 978-1-84950-378-5

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Article
Publication date: 1 August 1996

June H. Larrabee

Discusses challenges facing the US health‐care system now that prepaid or capitated health plans are gaining market share. Investigates how this affects providers, payers…

Abstract

Discusses challenges facing the US health‐care system now that prepaid or capitated health plans are gaining market share. Investigates how this affects providers, payers and policy makers and the concerns for the maintenance of a quality system. Concludes that the current changes in the US health‐care system are driven by the changing role of the consumer, concerns for quality and efforts to contain costs. Maintains that further research is needed to provide better guidelines to help these challenges to be met.

Details

International Journal of Quality Science, vol. 1 no. 2
Type: Research Article
ISSN: 1359-8538

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Article
Publication date: 1 August 2003

Saundra H. Glover, Karl J. McCleary, Patrick A. Rivers and Raymond A. Waller

A primary reason for the increase in uninsured Americans is due to the rising costs of health care that has caused a decline of employment‐based coverage for individuals…

Abstract

A primary reason for the increase in uninsured Americans is due to the rising costs of health care that has caused a decline of employment‐based coverage for individuals working for small firms. According to the 1997 US Census Bureau figures, 43 percent of uninsured worked full‐time, and eight out of ten of the uninsured or their dependents were full‐time workers. While significant improvements at the state‐level have occurred to address the unmet health insurance needs of children, less emphasis has been placed on ways to improve access and utilization of health services for uninsured adults. This paper revisits where the health care debate has been over the last decade, system stresses currently being felt by providers in caring for the uninsured population, and the adequacy of the care which they receive. In addition, several incremental strategies for extending Medicaid coverage for children and their families, costs and financing projections, and implications for providers are examined.

Details

International Journal of Social Economics, vol. 30 no. 8
Type: Research Article
ISSN: 0306-8293

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Article
Publication date: 2 May 2008

Kristina L. Guo

This paper aims to examine the issue of quality of care in the US managed care system and to compare state‐level policies and programs. Specifically, it aims to describe…

Abstract

Purpose

This paper aims to examine the issue of quality of care in the US managed care system and to compare state‐level policies and programs. Specifically, it aims to describe five states which are making the most quality of care improvements.

Design/methodology/approach

This study examines the literature to identify states' care quality rankings. Additionally, five state case studies are presented to illustrate various programs approach to quality.

Findings

The paper finds that some states are better than others in their strategies to enhance quality of care. California, Florida, Maryland, Minnesota and Rhode Island are considered among the best. Thus, their programs are described.

Research limitations/implications

From a research perspective the study brings a renewed focus on various methods in which states invest to improve residents' quality of care.

Practical implications

From a practical standpoint, since quality of care is an important topic and interesting to all stakeholders in health care – policymakers, consumers, providers, and payers – readers can use the study's results to compare states' strategies and develop new ways to increase quality.

Originality/value

This study's value lies in the way it helps states to compare their performance over time and against other states as they make improvements to enhance quality.

Details

International Journal of Health Care Quality Assurance, vol. 21 no. 3
Type: Research Article
ISSN: 0952-6862

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